Treatment Options

• Periodontal Therapy in Female Patients:
  • Hormonal changes affects the therapeutic decisions in disease. Some of the female cyclic phases include: puberty, menses, pregnancy, menopause, and oral contraceptives.
  • Puberty
    • Education of the parent or the caregiver
    • Preventive care including OHI
    • Scaling and root planing with frequent OHI
    • Antimicrobial mouthwashes
    • Susceptible eating disorders; therefore clinician must be aware of signs gastric content on the intraoral tissue.
  • Menses
    • Increase gingival bleeding and tenderness is associated with menstrual cycle. Antimicrobial rinses before cyclic inflamition is indicated 3-4 interval should be recommended.
    • Oral hygiene should be emphasized.
    • Schedule appointments for surgical visits after menstruation
    • Anemia is common so keep in contact with physican. Clinician should be aware of NSAIDs and infection and acidic foods exacerbate GERD.
    • Fluoride rinse in trays and frequent perio debridement.
    • Avoid mouthwashes with high alcohol content.
  • Pregnancy
    • A thorough medical assessment in essential with women that are pregnant
    • Plaque Control; tendency of increased gingival inflammation
    • Scaling, polishing, and root planning should be done whenever necessary.
    • Prenatal fluoride treatment
    • ADA does not recommend the use of fluoride prenatally.
    • Avoid elective dental care in the first trimester and the last half of the third trimester.
    • Radiographs:When needed during pregnancy the most important age for patient is to wear a lead apron.
    • Drug thearpy in pregnant women is controversial.
  • Oral Contraceptives
    • Treatment of gingival inflammation exaggerated by over the counter should include establishing an oral hygiene program and eliminating predisposing factors.
  • Menopause
    • Review medical history and maintaine current information
    • Dentist needs to be in contact with the physician for patients with osteoporosis.

• Periodontal Therapy in Medically Compromised Patients:
  • Cardiovascular Disease
  • Endocrine Disorders
  • Renal Diseases
  • Liver Diseases
  • Pulmonary Diseases
  • Immunosuppresion and Chemptherapy
  • Radiation Therapy
  • Prosthetic Joint Replacement
  • Pregnangy
  • Hemmoragic Disorders
  • Blood Dyscrazias
  • Infectious Diseases

• Periodontal Treatment for Older Adults:
  • An 85 year old man is brought in by his caregiver for a 6 mos recare visit. His cheif complaint is that "he is having a hard time brushing his teeth"
    • To treat this patient our main concern would be to decrease bacteria through oral hygiene and mechanical debridement.
      • OHI would include an electric toothbrush and a daily fluoride rinse.
  • The following are general considerations and recommendations to treat older patients:
    • Short appointments, late morning or early afternoon appointments, possible use of sedative oral medications or nitrous oxide/oxygen
      • If patient suffers from stress, to reduce a cardiovascular eve
    • Change chair position slowly, assist, and support
      • Syncope, Patients with disabilities, orthostatic hypotension, dexterity
    • Medical Consult
      • For patients with systemic diseases, drug to drug interactions with anesthesia, change in medications during treatment, use of vasoconstrictors. Older patients are at greater risk for infections and reduced healing
      • Evaluate medical history to identify and assess medical and mental status, medications, funtional status, and lifestyle behaviors that influence periodontal treatment outcome, or progression of disease, ability to tolerate treatment.
      • Clinical evaluation to assess periodontal disease severity, ability to perform oral hygiene procedures, remaining periodontal support, past periodontal destruction, occlusion.
      • Address both surgical and nonsurgical procedures.
      • Age is not a contraindication for periodontal treatment. It is based on the individual patients health status.
      • Age is not a risk factor for recession. It is often seen in older individuals, but it is not directly related to age.

• Treatment of Aggressive and Atypical Forms of Periodontitis:
  • A 20 year old patient presents in chair with no signs of inflammation and no recession, upon probing the patient there was minimal bleeding on probing, low bleeding index and generalized probing of 3mm with localized areas of 9-11mm probing in the 1st molar areas and the incisors of the mandibular right quadrant. Patient's FMX reveals localized severe bone loss. You look at patients previous radiographs which were taken two years ago and there were no signs of bone loss. Patient states that her "mother had long teeth too." Patient presented with localized aggressive periodontitis, treatment options for this patient includes: Surgical resection- this would be best for a patient who presented with deep pockets.
    • Surgical regeneration- this would be best for a patient that presented with angular bone defects and/or infrabony pockets.
    • Systemic antibiotics-these would be best for patients who present with localized or generalized aggressive periodontitis.
    • Full mouth disinfection-this would be best for patients who present with localized or generalized aggressive periodontitis.
    • Patient education- This would be beneficial for every patient so they can understand their condition and how to best manage it.

• Treatment of Acute Gingival Disease:
  • This condition is usually identified as acute necrotizing ulcerative gingivitis (ANUG). This condition usually results from an impaired host response to a potetntially pathogenic microflora. Depending on how immunicompromised the patients is, that will determine the severity of ANUG and any other underlying chronic gingival disease that may be present. The primordial important treatment of this condition is to alleviate the symptoms and to possibly correct any existing chronic gingival disease.

• Treatment includes and is not limited to the following:
  • A health history should be completed by asking any of the following: current illness, dietary background, type of employment, living conditions, hours of rest, cigarette smoking, risk factor for HIV, and possible stress or depression.
  • Observe any of the following: palpations of swollen lymp nodes (submaxillary/suglingual), presence of halitosis, general appearance, any skin lesions, vital signs possible temperature.

• First appointment: is concentrated in removing as much microbial load and nectrotic tissue by isolating the area with cotton rolls and dried by then leaving topical in the area for 2-3 minutes. Next step is to gently swabb the areas with a wet cotton pallet in small areas. This should remove the pseudomembrane and nonattached surface debri while at the same time profuse bleeding is occuring. Once the area is cleansed with warm water, supracalculus can be removed and an ultrasonic can possibly be used (supra) and aid with washing away some of the area.
  • Some of the patients with severe ANUG can benefit from taking amoxicillin, 500mg orally every 6 hours for ten days or erythromycin 500mg every 6 hours or metronidazole 500mg every 6 hours for 7 days
  • The patient is to avoid tobacco, alcohol, condiments, rinse with 3% hydrogen peroxide and warm water every 2 hours or twice daily with 0.12% chlorhexidine solution. They need to get planty of rest, confine from toothbrushing, and use an analgesic (NSAID) for pain relief.
• Second visit: should be at 1-2 days after the first visit and the gingival inflammation should be of less degree as well as having less pain.
  • The gingiva may still appear erythematous, but without a superficial pseudomembrane. If the gingiva did reduce, there may be superficial calculus that can be removed at this time and all the post-op instructions are the same as the first appointment.
• Third visit: 5 days after the second visit which at this point the patient is usually symptom free. This is the appointment where a complete periodontal evaluation takes place. A comprehensive plan for the management of the patient's periodontal evaluation is determined and plaque control instructions are given. Hydrogen peroxide rinses are discontinued, but the chlorhexidine rinses can be continued for 2-4 weeks. Scaling and root planning are done if needed as well as treating chronic periodontitis, pericoronal flaps, and periodontal pockets. Further counceling on smoking cessation, nutrition and other habits or conditions associated with potential recurrence should be continued.
  • Unfortunately, many patients after they are symptom free will not continue treatmen,t but at this time a comprehensive treatment should start based on the patient's chronic periodontal problem.

• Treatment of Periodontal Abscess:
  • Patient Background: Patient received periodontal therapy 2 months ago in Mexico, with no anesthesia. Patient complains of tender gums #24, "pus" #24, swelling #24, sensitive upon pressure and brushing #24.
  • E & I revealed enlarged lymph nodes submandibular region.
  • Clinically the area around #24 was:
    • painful, erythematous, was +2 mobility, slightly elevated in socket, tender to pressure, suppuration, vital pulp test, draining fistula
  • Radiographs reveal large calculus deposit mesial interproximal contact #24, vertical defect on mesial aspect of teeth
  • Probe depths were ; 446 (distal to mesial, buccal) 754 (mesial to distal, lingual)
  Treatment of abscess:
  • Treat acute symptoms:
    • Drainage through pocket retraction or incision
    • scale and root plane
    • perio surgery
    • antibiotics
    • tooth removal